MSF TB Program for Migrants in Tak

Beginnings: MSF TB Programs in Thailand

• First MSF TB Program in Thailand started in 1985 in Karen camps (Shoklo, Maela)

• Residential TB programs with high cure rate and low default rate (AFB (+ ): cure rate = 79,5% completed rate = 5,6% ; default rate = 5,6%)

• Programs not aimed at highly mobile populations crossing the border frequently

Migrant Healthcare: Multiple Challenges

• Large unregistered population of migrants in border areas; Tak province alone with estimated 75,000 to 150,000 unregistered migrants

• Barriers to medical care:

-cost

-security concerns (deportation)

-linguistic and cultural barriers

MSF Migrant TB Program: Planning

• MSF pilot study of migrant factory workers in Maesod in 1999: undertaken with Thai public health and with MSH (Dr. Witaya)

• Census: 71 factories assessed; estimated migrant factory population of 16,000

• Random sample of 1000 workers from census: primarily young adults, 72% single, intermediate education level, only 11% speak Thai, most work >6m in same factory, basic housing conditions- overcrowding with enhanced chance of spreading communicable disease

• Not included in census: day workers, farmers

MSF TB Program for Migrants: Implementation

• MSF TB program reviewed by Thai National TB program advisors and WHO technical advisors to ensure collaboration with Thai national TB program and implementation of DOTS in Thailand; DOTS launched on a national scale in 1996

MSF TB Program for Migrants: Objectives

Target Population:

1) Factory Workers (est. 16,000)

2) Day workers (est. 10,000)

3) Farmers (rural population, difficult to access)

4) Patients crossing from Myanmar for medical care in Thailand

Target Area: Maesot, Tak province and 20 km radius; later extended to Phoe Phra

MSF TB program

TB Village, Maela Camp

Chest Clinic, Maesod

DOTS Program

TB education for migrant factory workers

MDR Program

Chest clinic, MaesodReferral sources: Self (factory teachings, etc.), Maesod

Hospital, Mae Tao Clinic

Facilities: Complex with 14 patient rooms, lab, pharmacy, consultation room

Maesot TB team: 1 physician, 2 medics, 6 DOTS supervisors, 1 lab supervisor, 2 lab technicians, 1 driver; 1 cleaner and 2 cooks

Diagnosis and Treatment

• Diagnosis: Sputum x 3, no culture; other diagnostic modalities: CXR, fine needle aspiration, lymph node biopsy, thoracentesis.

• Treatment: WHO short course

Category 1: 2HERZ/4HR

Category 2: 2HERZS/HERZ/5HER

Category 3: Same protocol as category 1

DOTS Program• All TB treatment by DOTS short course; RX 6 times per

week in Mae Sod and 3 times per week in Phoe Phrae

• Patient population: migrant, undocumented, movements restricted

• DOTS team meets patient at home or workplace by motor bike or car

• Patient identification cards

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MEDECINSSANS FRONTIERES

Age and Sex of 311 M+ patients enrolled between Nov. 15, 1999 and Dec. 31, 2002

• Age Group Male Female Total

0-14 8 8 16

15-24 50 35 85

25-34 68 34 102

35-44 42 21 63

45-54 18 12 30

55-64 10 2 12

65+ 3 0 3

Treatment Outcome in 311 new M+ Patients enrolled between Nov. 15, 1999 and Dec. 31, 2002

• Outcome Number (%) of patients• Cured 215 (69.1%)• Completed 2 (.6%)• Transfer out 11 (3.5%)• Default 61 (19.6%)• Died 8 (2.6%)

success rate(cure +tx completed)=217/311 (69.7%)

Treatment Outcome in 508 patients enrolled between Nov. 15, 1999 and Dec. 31, 2002

Outcome Number (%) of patients

Cured 256 (50.4%)

Completed 100 (19.7%)

Transfer out 14 (2.8%)

Default 72 (14.2%)

Failed 51 (10.0%)

Died 15 (3.0%)

success rate (cure + tx completed)=356/508(70.1%)

Treatment Outcome of 63 Cross Border patients enrolled between Nov. 15, 1999 and Dec. 31, 2002

Cured=6/63 (57%)

Completed=5/63 (8%)

Default=17/63 (27%)

Fail= 3/63 (5%)

Die= 2/63 (3%)

In 2003, 54 cross border patients enrolled in DOTS, 17(31%) have already defaulted during tx.

Another 10 pts did not start tx (default before tx).

Factory TB education and screening

• Factories in Mae Sot area with 20 to 2,000 migrant workers

• TB education program launched November 2002: TB transmission, symptoms, diagnosis, treatment discussed

• Offer of diagnostic sputum testing and treatment free of charge

• 37 factories visited in 2003 with approximately 6,500 workers attending sessions

Conclusions

• DOTS program for migrants has cure rates less than WHO target of 85% but given highly mobile population can be considered a success

• Keys to success:

-security issues: medications brought to migrants;

ID cards

-coordination with other groups: Thai public health, MSH,

WHO, Mae Tao Clinic, local authorities

-culturally sensitive Burmese-speaking staff

Conclusions -2

• DOTS Weak Points:

-Program requires considerable investment of staff

and resources

-High default rates for ambulatory DOTS patients

from Myanmar: cost, security concerns,

inconvenience; other strategies: education based

program, patient access on Myanmar side

-No HIV testing or education done

Conclusions -3

Factory Education: Targeted education and case finding in factories worthwhile but program is hindered by continuing problems accessing factory owners (distrust of NGOs)